Provider Demographics
NPI:1104104611
Name:MORITSUGU, KENNETH PAUL (MD, MPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:MORITSUGU
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9561 BELL DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-3723
Mailing Address - Country:US
Mailing Address - Phone:408-726-1014
Mailing Address - Fax:
Practice Address - Street 1:9561 BELL DR
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:VA
Practice Address - Zip Code:22066-3723
Practice Address - Country:US
Practice Address - Phone:408-726-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00279572083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine